RIO HONDO COLLEGE NURSING PROGRAM CORRELATION MAP

STUDENT NAME: _Diana Ramos______________

PT OPTIMAL FUNCTION Pt history: Has had intermittent fever up PT INITIALS: C.L. AGE: 5 STRESSORS 1/4 pt to 12 days prior to admission. Abdominal SEX: Male 1/4pt pt 1. Understand disease process in pain, vomiting, headache, cough and fatigue ALLERGIES: Fish 1. Knowledge deficit native tongue 4 days prior to admission. On 4/11/12 pt. 2. Imbalanced diet 2. Ingest nutritionally adequate became unresponsive and experienced a 3. Fever diet for age tonic/clonic seizure which lasted approx. 3 4. Anxiety 3. Regain or maintain appropriate min. body temperature for age and size 4. Appear relaxed pt Erickson stage: Initiative vs Guilt MEDICAL DIAGNOSIS: Pt. took the initiative to request his father clean his Meningoencephalitis- Secondary diagnosis: Anemia and Single Seizure perineal area when giving him his bed bath. Pt. followed directions when given his medications. Pt. expressed great joy being able to play Mario Cart and able to win over his father. NANDA #1 PATHOPHYSIOLGY NANDA #2 1/2 pt Meningitis is an inflammation of the 1/2pt pt meninges, which could be caused by either P: Imbalanced Nutrition: Less than bacterial or viral agents. Most common P: Anxiety related to body requirements related to infection in the CNS. Bacterial meningitis E: Deficient knowledge in disease process and E: Energy level low/ fatigue to meet is more virulent than viral meningitis and is management sometimes fatal. nutritional needs secondary to S: Stress Response S/S S/S: Febrile, confusion, delirium or infection secondary to meningitis Mother crying impaired consciousness. May be irritable or S:Stress Response S/S Father asking several question regarding medications lethargic, vomiting, muscle or joint pain, Anemia (RBC 3.79, Hgb 9.9, Hct 29%) given headache, sinus or ear infection, nuchal Lack of interest in food. Mother asking what to expect with the procedure rigidity. Pale color skin. Spanish being their first language Anemia is a decreased in number of red Low potassium level- 3.2 Worried blood cells, amount of hemoglobin, and Low sodium level- 134 volume of packed red cells to less-thanFever up to 103.1 for up to 14 days normal levels. Results from an inadequate Vomiting supply of iron/ nutritional balance Headache

Desired outcome: Establish a dietary pattern with caloric intake adequate to regain or maintain appropriate weight within 24 hours

Desired outcome: Following interventions/treatments, child/parents will verbalize and demonstrate decreased anxiety

Diagnostic Tests 1/4 pt MRI brain- Probable small b/l frontal subdural empyema, up to 5.8 mm thick on the left and 4.9 mm on the right, with mild enhancement of adjacent meninges. Nursing Interventions /rationales 1 pt Assess food preferences and offer small, frequent servings of nutritious foods. - Optimally, these measures will promote eating Administer intravenous fluid and electrolytes, as indicated Used to correct fluid and electrolyte imbalance If appropriate, allow family to bring food from home. - Patient may prefer home-cooked meals to those prepared at the hospital. Medications-list name/category only Cefotaxime (CLAFORAN)- Beta-lactam antibiotic; Third generation cephalosporin Phenytonin (DILANTIN)- Anticonvulsant D5-NaCL 0.45% with KCL 20mEqHypertonic solution Acetaminophen (TYLENOL)- Nonnarcotic analgesic; Antipyrectic Ibuprofen (CHILDRENS ADVIL/MOTRIN)- Analgesic; NSAID; Antipyrectic

Lab values L: low H: high 1/4 pt L- RBC 3.79 L- Na 134 L- Hgb 9.9 H- CRP 192.7 L- 29 % H- ESR WEST > 120 H- WBC 14.9 L- K 3.2 Nursing Interventions /rationales 1 pt Explain all procedures/interventions performed on child to child and parents - Knowledge often helps decrease anxiety and promotes family-centered care. Keep parents informed of childs progress, including what is being done and why. - This decreases parents anxiety. The child easily perceives parental anxiety. Talk quietly and calmly to parents and to child in ageappropriate language. Reassure child and parents that you are available and will be there to help. - Establishing rapport increases trust and decreases anxiety.

Teach importance of well-balanced, nutritious intake. - Providing age-appropriate guidelines to children as well as to parents may help them in making healthy choices

Facilitate coordination of care. - This avoids disturbing disturbing any more than necessary, which would otherwise increase anxiety level. Use a Spanish translator. - Since English is not the primary language, speaking in their tongue may reduce parents anxiety and help them understand better.

Outcomes/Adaptation 1/4 pt Goal met: Patient removed from I.V. fluid, eating small meals.

Teaching: include diet, meds, activity, care Teach the importance of a well-balanced diet, especially iron intake, if appropriate, which is found in foods such as red meat, dark green vegetables, legumes, and certain fruits. Teach proper technique of hand washing Teach the importance of medication compliance

Outcomes/Adaptations 1/4 pt Goal partially met: The parents seem comfortable with the procedures being performed on child. Trust was established with both child and parents, as the father asked me if I could come in the next morning to help his wife out with translation and ensure his wife understood what was being performed. It was unmet due to not having a professional translator on hand. The father spoke and understood English but Spanish was there primary language. Recommendations: Have a translator on hand and have parents verbalize they understand the disease process to ease their anxiety.

Other concerns/problems: